Provider Demographics
NPI:1265724314
Name:OLSEN, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-1211
Mailing Address - Country:US
Mailing Address - Phone:631-697-4451
Mailing Address - Fax:
Practice Address - Street 1:77 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-1211
Practice Address - Country:US
Practice Address - Phone:631-697-4451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1129140174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist